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Electrical Injuries: A Review For The Emergency Clinician
As usual, the emergency department is hopping. Two minutes before change
of shift, a trauma patient rolls in—an electrician in his mid-30s brought in
by his coworkers. The patient, who was found unconscious near the generator he was repairing, is awake and alert but amnesic, with burns over his
chest and both arms. His vital signs are within normal limits. A number of
management questions enter your mind, including the need for a cardiac
evaluation and hospital admission. As you begin formulating a plan, the
nurse tells you that a young woman has arrived after “getting shocked” by
her hair dryer, which she was using while standing on a wet bathroom floor.
She has no obvious injuries or complaints other than very mild erythema
of her right palm. The nurse asks if you want to order an ECG or send any
blood tests.
It is unusual to have 2 electrical injuries in a single night. No sooner
has this thought crossed your mind than the nurse announces that EMS
has brought in 3 campers whose tent was struck by lightning. One camper
is in cardiac arrest with ongoing resuscitation for more than 10 minutes,
another has blood coming from his ears and complains of difficulty hearing,
and the third has pale, mottled, and numb lower extremities. While cursing
yourself for having taken a position with single physician coverage, you
quickly begin triaging these patients.
E
lectrical injury is not a common presentation in the emergency
department (ED). Nonetheless, every emergency clinician will
encounter at least one case during his or her career. Electrical injuries cause 5000 patients to seek emergency treatment each year
and are responsible for approximately 1000 deaths annually in the
Editor-in-Chief
Andy Jagoda, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Mount
Sinai School of Medicine; Medical
Director, Mount Sinai Hospital, New
York, NY
Editorial Board
William J. Brady, MD
Professor of Emergency Medicine
and Medicine Vice Chair of
Emergency Medicine, University
of Virginia School of Medicine,
Charlottesville, VA
Peter DeBlieux, MD Professor of Clinical Medicine,
LSU Health Science Center;
Director of Emergency Medicine
Services, University Hospital, New
Orleans, LA
Wyatt W. Decker, MD
Associate Professor of Emergency
Medicine, Mayo Clinic College of
Medicine, Rochester, MN
Francis M. Fesmire, MD, FACEP
Director, Heart-Stroke Center,
Erlanger Medical Center; Assistant
Professor, UT College of Medicine,
Chattanooga, TN
October 2009
Volume 11, Number 10
Authors
Amanda Dumler Czuczman, MD
Harvard Medical School, The Massachusetts General and
Brigham and Women’s Hospitals, Boston, MA
Richard D. Zane, MD
Vice Chair, Department of Emergency Medicine, Harvard
Medical School
Peer Reviewers
Mary Ann Cooper, MD
Emerita Professor, University of Illinois at Chicago, Chicago, IL
Brian J. Daley, MD, MBA, FACS
Professor of Surgery, Department of Surgery, University of
Tennessee Medical Center at Knoxville, Knoxville, TN
CME Objectives
Upon completion of this article, you should be able to:
1. Identify the most serious conditions associated with electrical
injury.
2. Recognize which patients require transfer and/or admission.
3. Develop an approach to treating lightning strike victims.
4. Discuss the controversies and need for more research with
regard to cardiac monitoring following electrical injuries.
Date of original release: October 1, 2009
Date of most recent review: May 20, 2009
Termination date: October 1, 2012
Medium: Print and online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see “Physician CME
Information” on the back page.
This article is eligible
for trauma CME credits.
University, Washington, DC; Director
Thomas Jefferson University,
of Academic Affairs, Best Practices,
Philadelphia, PA
Inc, Inova Fairfax Hospital, Falls
Scott Silvers, MD, FACEP
Church, VA
Medical Director, Department of
Emergency Medicine, Mayo Clinic,
Keith A. Marill, MD
Jacksonville, FL
Assistant Professor, Department of
Nicholas Genes, MD, PhD
Emergency Medicine, Massachusetts
Instructor, Department of
Corey M. Slovis, MD, FACP, FACEP
General
Hospital,
Harvard
Medical
Emergency Medicine, Mount Sinai
Professor and Chair, Department
School, Boston, MA
School of Medicine, New York, NY
of Emergency Medicine, Vanderbilt
Charles V. Pollack, Jr., MA, MD,
University Medical Center,
Michael A. Gibbs, MD, FACEP
FACEP
Nashville, TN
Chief, Department of Emergency
Chairman,
Department
of
Medicine, Maine Medical Center,
Emergency Medicine, Pennsylvania Jenny Walker, MD, MPH, MSW
Portland, ME
Assistant Professor; Division Chief,
Hospital, University of Pennsylvania
Family Medicine, Department
Steven A. Godwin, MD, FACEP
Health System, Philadelphia, PA
of Community and Preventive
Associate Professor, Associate
Michael S. Radeos, MD, MPH
Medicine, Mount Sinai Medical
Chair and Chief of Service,
Center, New York, NY
Department of Emergency Medicine, Assistant Professor of Emergency
Medicine, Weill Medical College of
Assistant Dean, Simulation
Ron M. Walls, MD
Cornell
University,
New
York,
NY.
Education, University of Florida
Professor and Chair, Department
COM-Jacksonville, Jacksonville, FL Robert L. Rogers, MD, FACEP,
of Emergency Medicine, Brigham
FAAEM, FACP
and Women’s Hospital, Harvard
Gregory L. Henry, MD, FACEP
Assistant
Professor
of
Emergency
Medical School, Boston, MA
CEO, Medical Practice Risk
Medicine,
The
University
of
Assessment, Inc.; Clinical Professor
Scott Weingart, MD
Maryland School of Medicine,
of Emergency Medicine, University
Assistant Professor of Emergency
Baltimore, MD
of Michigan, Ann Arbor, MI
Medicine, Elmhurst Hospital
Alfred
Sacchetti,
MD,
FACEP
Center, Mount Sinai School of
John M. Howell, MD, FACEP
Assistant Clinical Professor,
Medicine, New York, NY
Clinical Professor of Emergency
Department of Emergency Medicine,
Medicine, George Washington
Research Editors
Lisa Jacobson, MD
Chief Resident, Mount Sinai School
of Medicine, Emergency Medicine
Residency, New York, NY
International Editors
Peter Cameron, MD
Chair, Emergency Medicine,
Monash University; Alfred Hospital,
Melbourne, Australia
Amin Antoine Kazzi, MD, FAAEM
Associate Professor and Vice
Chair, Department of Emergency
Medicine, University of California,
Irvine; American University, Beirut,
Lebanon
Hugo Peralta, MD
Chair of Emergency Services,
Hospital Italiano, Buenos Aires,
Argentina
Maarten Simons, MD, PhD
Emergency Medicine Residency
Director, OLVG Hospital,
Amsterdam, The Netherlands
Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education
(ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr.
Czuczman, Dr. Zane, Dr. Cooper, Dr. Daley, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s)
discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
United States. They also represent 2% to 7% of all
admissions to burn units.1-4 Patients with electrical
injuries represent a special challenge because they
encompass a wide spectrum of presentations—
from thermal burns to arrhythmias to spinal cord
injuries—that the emergency clinician, by definition,
must know how to assess and treat.
Half of electrical injuries occur in the workplace2,5 and many result in litigation for negligence,
product liability, or workers’ compensation.6-7 Highvoltage injuries have the highest potential for legal
consequences as they usually involve young men at
the height of their earning capability.1,2,4
2006 use Class II and Class III evidence and are most
helpful for determining when cardiac monitoring is
required. Table 1 summarizes these guidelines.
Etiology And Pathophysiology
Electricity is the flow of electrons. It can be expressed as voltage (V) and as current (I), which is
measured in amperes (A). The obstruction to flow is
the resistance (R). According to Ohm’s law, I = V /
R, current is directly proportional to voltage and inversely proportional to resistance. A plumbing analogy is often used: amperage is the volume of water
flowing through a pipe; resistance is the diameter of
the pipe; and voltage is the difference between the
entrance and exit pressures of the pipe. The damage
incurred during an electrical injury depends upon
the voltage, the resistance of tissues, the amperage
(or current strength), the type of circuit (direct or
alternating current), the current pathway, and the
duration of contact.3,9
The safe range of human exposure to electric
currents is narrow because of the small difference
between the threshold of perception of current
(about 0.2 to 0.4 mA) and the “let-go current” (about
6 to 9 mA for an adult).3,10 Amperage that exceeds
the let-go current causes tetanic muscle contractions
that prevent the release of the electrical source. (See
Table 2). The let-go current is much more likely to
be reached with exposure to alternating current (AC)
than direct current (DC). Because the hand is the
most common site of contact with a current source
and the flexors of the upper extremity are much
stronger than the extensors, when the let-go current is exceeded, the arm flexes and pulls the body
closer to the source. Thoracic muscle tetany occurs
just above the let-go current and causes respiratory distress. This reaction can be provoked by any
electrical source, including transcutaneous electrical
nerve stimulators, which caused tetanic paralysis of
the chest wall and respiratory arrest in one patient.11
Ventricular fibrillation is also estimated to occur at
surprisingly low amperages.12-15
Critical Appraisal Of The Literature
Few prospective randomized controlled trials have
been conducted on electrical injuries, so clinical
practice is based on retrospective reviews and the
general burn literature. This issue of Emergency
Medicine Practice focuses on the challenges of evaluating and managing electrical injuries using the best
available evidence from the literature. PubMed®
(limits: English human trial, clinical trial, metaanalysis, practice guidelines, randomized controlled
trial, and review), MD Consult journals/MEDLINE®,
and Ovid MEDLINE® were searched for all literature published from 1966 to 2008 using the terms
emergency AND electrical injury. The searches provided 120 articles; 65 were reviewed and found to be
relevant. Additional resources were identified using
reference lists from the reviewed articles. No information was added from searches of the American
College of Emergency Physicians® (ACEP) clinical
practice guidelines, the National Guideline Clearinghouse™ (www.guideline.gov), or The Cochrane
Database of Systematic Reviews.
Many controversies surround the care of electrical injuries, including the role of cardiac monitoring.
Practice guidelines developed by Arnoldo et al8 and
published in the Journal of Burn Care and Research in
Table 1. Practice Guidelines For Cardiac
Monitoring After Electrical Injuries
Characteristic
Cardiac monitoring NOT required if ALL the following are true
Cardiac monitoring
IS required if ANY
of the following
are true
Electrocardiogram Normal
Documented arrhythmia or
evidence of ischemia
History of loss of consciousness
No
Yes
Type of injury
Low-voltage (≤ 1000 volts) High-voltage
(> 1000 volts)
Emergency Medicine Practice © 2009
Table 2. Physiologic Effects Associated With
Various Electric Current Strengths3,10
2
Current Strength (mA)
Physiologic Effect
0.2 - 2
Tingling sensation perceived
3-5
Let-go current for a child
6-8
Let-go current for an adult woman
7-9
Let-go current for an adult man
10 - 20
Tetany (inability to release source)
20 - 50
Respiratory arrest secondary to thoracic muscle tetany
50 - 100
Ventricular fibrillation
EBMedicine.net • October 2009
Tissues vary in their resistance to electrical
flow. Nerves, muscle, and blood vessels have a
low resistance and are good conductors of electricity. Tissues that offer greater resistance are more
likely to transform electrical energy into heat. For
example, bone, tendon, and fat have the highest
resistance and tend to heat up and coagulate.3 As a
consequence, internal muscle damage from electric
current may be much greater than damage to more
superficial muscles and soft tissues. Skin offers the
primary resistance to electric current and dissipates
much of the energy across its surface. Dry skin
has intermediate resistance, but this is markedly
reduced by moisture. Although each body tissue
has a unique level of resistance, together they form
a composite resistance.7
Because the body’s resistance to electric current
changes as the tissues break down, the only sure measure of a patient’s electrical exposure is the voltage.
Electrical injuries are traditionally (and arbitrarily)
divided into high-voltage and low-voltage exposures.
(See Table 3). A high-voltage exposure is defined as
exposure to more than 1000 volts. A further distinction is made between injuries caused by high-voltage
current that has direct contact with the body and flash
injuries, which are caused by exposure to a highvoltage arc that stretches between the source and the
victim.16 The arc may generate temperatures up to
5000°C (9032°F) and ignite clothing, resulting in secondary thermal burns.17 Low-voltage exposures include common household circuits in the United States
and Canada, which provide 120 volts for general use
and 240 volts for high-power appliances.5
It is important to distinguish between AC and
DC. Most homes and offices use AC, in which
electrons flow back and forth through a conductor
in a cyclic fashion, standardized at a frequency of 60
cycles per second (60 Hz). Direct current is used in
items such as batteries, automobile electrical systems,
and high-voltage power lines. Exposure to DC causes
a single muscle contraction that throws the victim
away from the electrical source, whereas exposure
to AC causes tetany that prolongs contact with the
source, making it potentially more dangerous.17
Electrical injuries have 3 clinical presentations:
(1) direct trauma from the electric current coursing
through the body, (2) trauma from conversion of
electrical energy to thermal energy, and (3) mechanical effects of the electric current, including violent
muscle contractions and falls.18 Emergent evaluation of electrical injuries should follow the traditional pathway of primary and secondary surveys,
followed by a detailed and specific history and
physical examination describing specific injuries by
system. Table 4 summarizes multi-system injuries.
Cutaneous Injuries
Burns are the most common injury associated with
electrical accidents. Low-voltage injuries tend to create small, well-demarcated contact burns at the sites
of skin entry and exit.16 In high-voltage injuries, the
burns are serious and appear as painless, depressed,
yellow-gray, charred craters with central necrosis.3
Although electrical burns often appear to be less
impressive than flame burns on the surface, appearance cannot be used to predict the severity of injury.
High-voltage injuries may largely spare the skin
surface but cause massive damage to underlying soft
tissue and bone, necessitating escharotomies, fasciotomies, or amputations.1,4 Fortunately, this level
of damage is rare after low-voltage electrical injuries.
In a prospective study by Blackwell et al of 212 lowvoltage electrical injuries, only 19 (9%) of the cases
involved significant cutaneous injury.19
The “kissing burn” is sometimes associated with
electrical injury. (See Figure 1.) This burn occurs at
flexor creases such as the antecubital fossa when a
current arcs across both flexor surfaces. It is important
to recognize this type of injury because it is often associated with extensive underlying tissue damage.10
Table 3. Comparison Of High-Voltage And
Low-Voltage Electrical Injuries17
Characteristic
Low-Voltage Injury
High-Voltage
Injury
Voltage, V
≤ 1000 V
> 1000 V
Type of Current
Alternating current
Alternating current
or direct current
Duration of Contact
Prolonged
Brief (if direct
current)
Cause of Cardiac
Arrest
Ventricular fibrillation
Asystole
Cause of Respiratory Arrest
Thoracic muscle
tetany
Thoracic muscle
tetany or indirect
trauma
Muscle contraction
Tetanic
Tetanic (if alternating current); single
(if direct current)
Burns
Superficial
Deep
Rhabdomyolysis
Less common
More common
Blunt injury
Does not usually
occur
Caused by falls
and violent muscle
contractions
October 2009 • EBMedicine.net
Cardiac
The most serious presentation of electrical injury is
cardiac arrest. It has been suggested that ventricular
fibrillation is more common with low-voltage AC
injuries, whereas asystole is seen more often with
DC high-voltage injuries.20 However, little clinical
data support this claim. Other initial electrocardiogram (ECG) abnormalities reported in prospective
studies include sinus tachycardia, right bundle
branch block, first-degree AV block, nonspecific
3
Emergency Medicine Practice © 2009
ST-segment anomalies, QT-segment prolongation,
and premature ventricular contractions.19,21 Atrial
fibrillation has also been documented in several case
reports.22,23
The incidence of arrhythmias after electrical injury ranges from 4% to 17%, as evidenced in numerous prospective and retrospective studies.1,19,21,24-28
Overall, exposure to low-voltage AC is most likely
to cause cardiac consequences as it increases the
likelihood of current flow through the heart during the vulnerable relative refractory period. The
mechanism behind electrically induced cardiac
arrhythmias is not entirely clear but may involve
patchy areas of myocardial necrosis that serve as
arrhythmogenic foci, as well as increased cardiac
sodium-potassium pump activity.13 Delayed arrhythmias are rare and tend to occur only in patients
with an arrhythmia on presentation, as has been
shown in multiple prospective and retrospective trials encompassing both low-voltage and high-voltage
injuries.19,21,24-27,29,30 Thus it is important to obtain an
initial ECG in the ED on all patients with an electrical injury, regardless of the voltage.
Electrical exposure may cause direct myocardial
tissue damage via transcardiac passage of the electric current or indirect damage via ischemic injury
precipitated by arrhythmia-induced hypotension or
coronary artery spasm. Direct myocardial damage
is thought to be caused by electric current flowing
vertically (head to foot), whereas arrhythmias are
more likely to be caused by electric current flowing
horizontally (hand to hand).9 Myocardial functional
abnormalities are demonstrated by echocardiography; this cardiac dysfunction may be either reversible or persistent.31 Myocardial infarction due to
acute coronary artery occlusion after electrical injury
appears to be rare.32,33
Autonomic dysfunction following electrical
injuries can cause serious cardiovascular complications related to the release of catecholamines. This
may lead to cardiac arrest, transient hypertension,
tachycardia, vasovagal syncope, thermodysregulation, and vasoconstriction.34 Patients with a history
of vasovagal reactions may be at increased risk of
sudden death from cardiac arrhythmia after an
electrical injury.35 Autonomic dysfunction has been
implicated in keraunoparalysis, a phenomenon seen
with lightning injury in which the extremities are
temporarily paralyzed.34
Figure 1. Kissing Burn3
High-voltage and low-voltage electrical injuries
affect both the CNS and peripheral nervous system
(PNS). Central nervous system lesions are more
common with lightning injury, while PNS lesions are
seen more often with electrical injuries. A retrospective review of 90 patients that focused on the neurologic consequences of electrical burns found that
50% of patients with low-voltage injuries and 67%
of patients with high-voltage injuries had immediate neurologic symptoms.38 The most common CNS
symptom was loss of consciousness. Other neurologic symptoms were acute peripheral neuropathy
and transient paralysis or paresthesia. However,
a 20-year review by Arnoldo et al1 involving 700
patients with electrical injuries showed that only 5%
had acute neurologic complications, although 25%
of patients went on to develop delayed neuropathies. More recently, a study of animal models has
cemented a direct link between electrical injury and
peripheral nerve damage.39
Respiratory
Respiratory arrest may immediately follow electric shock as a result of tetanic contraction of the
thoracic musculature, injury to the respiratory
control center of the central nervous system (CNS),
or combined cardiopulmonary arrest secondary to
asystole or ventricular fibrillation.9 Cardiac function
may spontaneously recover because of automaticity; however, if respiratory arrest persists, secondary
hypoxia develops. Blunt chest trauma due to falls or
being thrown from a high-voltage source may cause
pulmonary contusion.17
Vascular
Electrical injuries cause the greatest damage to the
media layer of blood vessels and can lead to delayed
aneurysm formation or rupture.10,17 Damage to the intima may result in thrombosis and occlusion immediately or over several days.36 Vascular injury following
electrical trauma is usually most severe in the small
muscle branches where the blood flow is slower; this
can create tissue necrosis.37 Any vascular injury can
also lead to edema and compartment syndrome.
Neurologic
(Reprinted by permission from Elsevier. This figure was published in
Rosen’s Emergency Medicine Concepts and Clinical Practice, Price
TG and Cooper MA, Electrical and lightning injuries, 2267-2278,
Copyright © Elsevier 2006.)
Emergency Medicine Practice © 2009
4
EBMedicine.net • October 2009
Spinal cord damage is the most common delayed consequence of electrical injury and may
resemble lower motor neuron disease, amyotrophic
lateral sclerosis, or transverse myelitis.40 The incidence of spinal cord injury following high-voltage
electrical trauma ranges from 2% to 27%.41 This type
of injury may occur when an electric current travels
from arm to arm or from arm to leg, with the site of
onset associated with current entry or exit.40,42 In a
case series that reviewed high-voltage entry sites in
the head and neck, an exit site in the lower extremities led to paraplegia, whereas an exit site in the
upper extremities led to quadriplegia.42 Electrical
injury has been proposed as a risk factor for amyotrophic lateral sclerosis; however, a recent systematic
review of the literature that identified 31 articles
found no support for a causal relationship.43 Nevertheless, these reviews clearly support a syndrome
of nonprogressive spinal cord damage after severe
electrical injury. Partial or even complete recovery
may occur, but delayed neurologic symptoms have
an overall poor prognosis.
plications including mastoiditis, sinus thrombosis,
meningitis, and brain abscess.47
Victims of electrical injury often experience a
wide range of neuropsychological issues including
depression, cognitive dysfunction, attention problems, anxiety, and chronic pain disorders such as
complex regional pain syndrome (CRPS) that may
be challenging to diagnose.48,49
Differential Diagnosis
A history of electrical exposure makes the diagnosis. However, for a person found unconscious
with unwitnessed cardiac arrest, it is appropriate
to keep electrical and lightning injuries in the differential if the environmental setting or weather
conditions warrant.
Prehospital Care
The primary goal during prehospital management of
patients with electrical injuries is to secure the scene.
The underlying theory presumes that if the victim is
still in contact with the electrical source, he or she (or
even the ground if it is wet) can become a conductor
and electrocute the rescuer, although no published
reports describe this. Before approaching the victim,
medical personnel should ensure that the power
source has been turned off. In high-voltage incidents, it is best to involve the local electric company.
Once the scene is safe, prehospital rescuers should
focus on aggressive and persistent cardiopulmonary
resuscitation (CPR), even if the victim appears to be
dead.51 Electrical injury victims are typically young
and healthy, so CPR has a higher chance of success.52
When effective high-quality CPR begins immediately, patients experience a quicker resumption of spontaneous circulation and have better outcomes.52,53 If
Musculoskeletal
Direct electrothermal energy leading to coagulation necrosis is the main cause of muscle injury and
usually occurs only after high-voltage exposures.
The damaged muscle may become edematous and
necrotic, resulting in rhabdomyolysis or compartment syndrome. As bone has the highest degree
of resistance, severe electrothermal bone damage
such as periosteal burns and osteonecrosis is seen.
Falls secondary to electrical injury and forceful
tetanic muscle contractions create fractures and joint
dislocations. In a well-designed retrospective study
spanning 20 years and 700 patients, Arnoldo et al1
reported 22 cases of fractures and 68 cases of muscle
necrosis following high-voltage electrical exposure.
Renal
Table 4. Summary Of Multi-system
Presentations Of Electrical Injuries50
The kidneys are susceptible to ischemia after severe
electrical injury. Muscle injury resulting in myoglobin release may also cause renal tubular damage
and subsequent renal failure.
Other
Cataracts develop in up to 6% of patients with highvoltage injuries and in many patients after lightning
injury.44 Cataracts may occur immediately but more
often develop months after the injury.45
Hearing loss is a well-known sequela of lightning injury and may also occur after electrical
injury.46 Mechanisms include rupture of the eardrum
by acoustic trauma, flow of electric current through
the cochlea, and hemorrhage. Patients with injury to
the eighth cranial nerve may also suffer from chronic
tinnitus and imbalance problems. Damage to the
middle or inner ear may result in infectious comOctober 2009 • EBMedicine.net
5
System
Presentation
Skin
Cutaneous burns
Cardiac
Arrhythmias, cardiac arrest
Respiratory
Respiratory arrest due to muscle tetany or
central nervous system causes
Vascular
Aneurysm formation, tissue ischemia
Neurologic
Loss of consciousness, transient paralysis or
paresthesia, peripheral neuropathy, spinal cord
injury
Musculoskeletal
Fractures or dislocations secondary to muscle
spasm or falls, muscle necrosis, compartment
syndrome
Renal
Myoglobinuria leading to renal failure
Other
Cataracts, neuropsychological effects
Emergency Medicine Practice © 2009
consciousness, or confusion. Bystanders and prehospital providers are a good resource regarding the
electrical source, the voltage, the duration of contact,
environmental factors at the scene, and resuscitative measures already provided.3 Special attention
should be paid to the electrical source; an injury that
initially appears to have resulted from a low-voltage
source (eg, a household appliance) may be due to a
high-voltage source (eg, a capacitor that is contacted
during repair of a television or microwave oven).10
Medical history (especially cardiac problems), medications, allergies, and tetanus immunization status
should also be obtained.
defibrillation or cardioversion is necessary, energy
levels recommended by standard Advanced Cardiac
Life Support (ACLS) protocols should be used (ie, no
adjustment should be made because of the history of
electrocution).54
Prehospital management of electrical injuries
includes routine care—the patient’s cervical spine is
immobilized with a cervical collar and backboard,
any fractures are splinted, and burns are covered
with clean, dry dressings. At least one large-bore
intravenous line should be established, and a fluid
bolus of 10 to 20 cc/kg of normal saline or Lactated
Ringer’s Solution should be given to any patients
with cutaneous burns or hypotension. The fluid
requirements of patients with electrical injuries are
generally much greater than those of patients with
thermal burns. (See the Treatment section.)
Transport to the closest appropriate facility
should begin after basic treatments are complete. Patients who have experienced a significant burn injury
should ideally be transported or transferred to a burn
center, and patients who have encountered a highvoltage injury should be taken to a trauma center.
Physical Examination
After a basic survey, a thorough but focused
physical examination should be performed, with
the size and location of any burns and the condition of the patient’s extremities noted. Small,
well-demarcated entry and exit wounds are often
seen with low-voltage electrical injuries whereas
depressed, necrotic-appearing burns are more
commonly observed in high-voltage injuries. An
assessment of vision and hearing should include
fundoscopic and otoscopic examination. During the otoscopic examination, clinicians should
look for tympanic membrane rupture, as this may
be the only clue of lightning injury in a patient
brought from the field.55 The full range of motion
of all joints should be tested to assess for fractures
and dislocations. Serial neurovascular checks on
all extremities are also necessary because vascular
damage and delayed compartment syndrome may
become apparent at any time.3,7
Emergency Department Evaluation
All electrical injuries should be evaluated and
managed as multisystem injuries. Initial stabilization of patients with electrical injury should follow
basic ACLS and Advanced Trauma Life Support®
(ATLS) algorithms. A difficult airway evaluation is
particularly important, as airway injury can progress rapidly in at-risk patients such as those with
burns involving the face, mouth, or neck. Aggressive fluid resuscitation to maintain perfusion as
measured by adequate urine output (1.0-1.5 cc/kg
per hour) should be initiated. If heme pigment from
rhabdomyolysis is present in the urine, urine output
must be constantly monitored. Electrical injuries
are similar to crush injuries, so formulas for fluid
resuscitation based on percentage of body surface
area burned are not applicable. It is critical to immediately remove any constricting objects such as rings
because edema may develop quickly.
Nevertheless, some patients with low-voltage
electrical injuries will be well-appearing with minimal signs of injury. These patients do not need to be
rushed to the nearest ED or approached as a trauma
patient. Common sense and the general appearance
of the patient will go a long way in recognizing this
subset of electrical injury victims.
All patients, whether exposed to low voltage or
high voltage, should have an ECG done on presentation to evaluate for arrhythmias.8
Diagnostic Studies
Electrocardiogram
In guidelines that are based on an extensive review
of the literature, Arnoldo et al8 recommend that all
patients receive an initial ECG to assess for cardiac
injury and arrhythmias. (See Table 1, page 2.) The
issue of additional cardiac monitoring is discussed
in the Controversies/Cutting Edge section.
Laboratory Tests
Table 5 lists the laboratory tests that should be performed in patients at risk for a conductive electrical
injury (ie, patients with entry and exit wounds or
cardiac arrhythmia) or in patients presenting with
injuries beyond minor cutaneous burns.
Serial creatine kinase (CK) levels should also be
drawn in patients with high-voltage injuries, as peak
CK levels predict muscle injury, risk of amputation,
mortality, and length of hospital stay.56,57 However,
great caution should be used when interpreting
cardiac markers in the setting of electrical injury.
Creatine kinase myocardial isoenzyme (CK-MB) lev-
History
Patients may not be able to provide a good history because of the severity of their injuries, loss of
Emergency Medicine Practice © 2009
6
EBMedicine.net • October 2009
els correlate poorly with myocardial damage.56,58-60
McBride et al found that among 36 victims of highvoltage electrical injury, 50% had abnormal CK-MB
levels, but only 2 patients sustained myocardial
infarctions according to history, ECG findings, and
clinical course.60 Troponin levels in electrical injuries
have not been studied.
Treatment
Cutaneous Injuries
Depending on transfer agreements with the local
burn center, burns should be cleaned and then covered with sterile dressings. If the burns are treated
locally, antibiotic dressings, such as mafenide acetate
or sulfadiazine silver should be used to cover the
wounds. Although scant evidence supports specific
uses, mafenide acetate is preferred for localized
full-thickness burns because it has better penetration, whereas sulfadiazine silver is preferred for
extensive burns because it is less likely to cause
electrolyte abnormalities.10 Tetanus immunization
status should be determined and patients vaccinated
as needed. Tetanus can occur in elderly patients who
have not had regular boosters and immigrants who
have never received a primary immunization series.
Clostridial myositis is a reported complication of
electrical injuries,65 but no evidence supports the use
of prophylactic antibiotics.
Radiology
Victims of electrical injury should be approached as
trauma patients. A head computed tomography (CT)
scan to evaluate for intracranial abnormalities may
be indicated in patients with electrical injury associated with a fall, persistent altered level of consciousness, or abnormal findings on neurologic examination. Plain films and/or CT scans of the spine should
be ordered if a spinal injury is clinically suspected.
Plain radiographs should be obtained in any area
where the patient has pain, an obvious deformity, or
decreased range of motion. There is a low threshold
for obtaining plain films of the shoulders and pelvis,
especially if these areas were in the path of the electric current, as there have been reports of delayed
diagnoses of shoulder dislocations and femoral neck
fractures.47,61
Late evaluation of tissue perfusion and occult
muscle damage prior to surgical exploration can be
done with technetium-99 pyrophosphate scintigraphy.62,63 Magnetic resonance imaging with gadolinium can be a helpful adjunct to technetium-99
pyrophosphate scanning to better localize areas of
muscle necrosis.62,64 Although there is not enough
data to recommend routine use of these imaging
modalities, they can be discussed with the trauma
surgeon on a case-by-case basis.
Management Of Injury To The Extremities
The upper extremities are frequently injured in
electrical trauma and can be a source of morbidity
and functional loss. A conundrum exists with such
injuries: If fasciotomy and surgical exploration are
not performed, deep muscle necrosis may be missed;
but if they are performed unnecessarily, the patient
may require multiple surgeries and have a protracted hospital and rehabilitation course. No prospective randomized controlled trials have assessed the
role of immediate surgical exploration, but recent
practice guidelines recommend a conservative approach, with the authors concluding that surgical
decompression (ie, fasciotomy and assessment of
muscle compartments) should only be performed if
the patient develops progressive neurologic dysfunction, vascular compromise, increased compartment pressure, or systemic clinical deterioration due
to suspected ongoing myonecrosis.8,65-74 No literature has been published on the management of the
lower extremities, but it seems reasonable to follow
the same guidelines.
When electrothermal burns affect an upper
extremity, the limb should be splinted with the wrist
at 35° to 45° of extension, the metacarpophalangeal
joint at 80° to 90° of flexion, and nearly full extension
of the proximal and distal interphalangeal joints (Z
position) to minimize the space available for edema
formation.10 The extremity should be kept elevated
above the level of the heart to reduce edema. Frequent neurovascular checks of all extremities are
crucial because compartment syndrome may become evident at any time.
Early orthopedic intervention in patients with
an electrical injury and major fractures is also
important. Fracture stabilization can be safely done
Table 5. Laboratory Tests Recommended
For Patients With Electrical Injuries
Test
Rationale/Indication
CBC
All patients with injuries beyond minor cutaneous burns
Electrolytes
All patients with injuries beyond minor cutaneous burns
BUN and creatinine
All patients with injuries beyond minor cutaneous burns
Urinalysis
To evaluate for myoglobinuria (positive for blood but no red blood cells)
Serum myoglobin
If urinalysis is positive for myoglobinuria
Liver function tests/
amylase/lipase
If intra-abdominal injury is suspected
Coagulation profile
If intra-abdominal injury is suspected or if surgical course is projected
Blood type and screen/crossmatch
If surgical course is projected
October 2009 • EBMedicine.net
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Emergency Medicine Practice © 2009
using internal fixation in the first 24 to 48 hours after
a thermal burn.75 Early fracture reduction allows for
ideal stabilization, better wound care, and earlier
patient mobility.
than ventricular fibrillation. The heart’s intrinsic automaticity may restore cardiac activity but concomitant respiratory arrest due to thoracic muscle spasm
or central respiratory depression may produce
hypoxia-induced ventricular fibrillation. Virtually
everyone who is struck by lightning will survive if
they do not experience cardiac or respiratory arrest. Thus, when multiple victims are present, triage
should be reversed; the highest priority should be
given to patients who are in cardiac or respiratory
arrest or who appear to be dead.51 Unlike patients
with electrical injuries who may still be in contact
with the electrical source, people who have been
struck by lightning do not remain “charged” in any
way and can be approached immediately.87 Dilated,
unreactive pupils are not an accurate indicator of
death because of possible ocular injuries and/or
autonomic instability following a lightning injury.
If a lightning strike occurs near a patient’s head,
it may enter the eyes, ears, or mouth. Tympanic
membrane rupture frequently occurs in these patients and usually resolves without serious consequences. Permanent deafness can occur secondary
to disruption of the ossicles. Ocular injuries such as
corneal lesions, macular holes, vitreous hemorrhage,
retinal detachment, and cataracts may occur after
lightning injury.88-90 Bilateral cataract formation is
common, though it may not develop for months or
even years after the initial injury.90
Four main types of superficial burns are seen in
lightning strikes: linear, punctate, feathering, and
thermal. Linear burns occur where sweat or water
have accumulated (eg, in the axilla or running down
the chest). Punctate burns resemble multiple small
cigarette burns and often appear in a rosette pattern. “Tip-toe signs”—characteristic small, circular,
full-thickness punctuate burns involving the sides
of the feet and the tips of the toes—were seen in half
of a group of 17 patients during a single lightning
strike.91 Feathering burns, also called Lichtenberg
figures, are pathognomonic for lightning injury.
(See Figure 2.) They usually appear within one hour
of the lightning strike and fade within a few days.
Feathering burns are not true burns and do not
require any treatment. Thermal burns may occur if
the patient’s clothing catches fire or if the patient is
wearing any metal objects that heat up and cause a
direct burn.3
Cardiac arrest is the primary cause of mortality in lightning injury; neurologic complications are
the principal cause of morbidity. Lightning-related
neurologic sequelae fall into 4 categories: immediate
and transient symptoms, immediate and persistent
symptoms, delayed symptoms, and traumatic lesions secondary to falls.92,93
Immediate and transient neurologic symptoms
include loss of consciousness, confusion, anterograde amnesia, weakness, and paresthesia. Although
these symptoms are purportedly very common, sup-
Myoglobinuria
Myoglobinuria is a common and concerning finding
in patients with electrical injuries because it places
them at risk for renal failure. Fluid resuscitation
should be directed at maintaining a urine output
of 1.0 to 1.5 cc/kg per hour until the urine is clear
of myoglobin. Acute myoglobinuric renal failure
with life-threatening consequences can occur if fluid
resuscitation is delayed.76 Some authors advocate
the use of sodium bicarbonate (1 ampule or 50 meq
added to each liter of fluid) to alkalinize the urine
and mannitol (25 g every 6 hours) or furosemide to
supplement diuresis.1,47,77,78 No evidence supports
these practices, and they are mentioned here for
completeness only.
Viscera
Although it is uncommon, electrical injuries may
cause injury to the abdominal organs. In a review of
226 patients with either high-voltage or low-voltage
electrical injuries treated at a single burn center, 4
patients (0.4%) suffered from visceral injuries.79 All
4 patients sustained high-voltage electrical injuries
involving the abdomen. The colon is the most commonly injured visceral organ, though there are case
reports of injury to the small intestine,80 gallbladder,81,82 and pancreas.83 It may take 2 to 3 days post
burn for the true level of visceral involvement to
become clear.84
Special Circumstances
Lightning Injuries
Lightning strikes cause more deaths per year on average than any other storm condition except for flash
floods and river floods combined.85 The National
Oceanic and Atmospheric Administration documented 9818 injuries and 3239 deaths due to lightning during a 36-year period in the United States,
an overall mortality rate of 32%.85 Certain weather
conditions, namely graupel (a type of frozen precipitation that resembles snow pellets or soft hail),86
indicate that lightning strikes are likely.
Lightning behaves as an instantaneous, massive, unidirectional current. It is initially transmitted
internally and then flashes over the body. Its voltage
may exceed 1 million volts, but it dissipates within
milliseconds. Because of the brief duration, lightning
strikes rarely cause significant burns or soft tissue
destruction, but they are more likely to result in
cardiac and respiratory arrest, neurologic sequelae,
and autonomic instability. Lightning depolarizes the
entire myocardium and produces asystole rather
Emergency Medicine Practice © 2009
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EBMedicine.net • October 2009
porting data from retrospective reviews are sparse.
In a retrospective review of 22 lightning strike
victims in Turkey, only 5 complained of confusion
and amnesia, though loss of consciousness was not
measured.94 Keraunoparalysis is a transient neurologic paralysis that is pathognomonic for lightning
injury. Keraunoparalysis is characterized by lower
and occasionally upper extremities that are numb,
blue, mottled, cold, and pulseless. Thought to be
caused by transient vasospasm and autonomic nervous system dysfunction, keraunoparalysis usually
resolves on its own within a few hours.95
Immediate and persistent neurologic syndromes
associated with lightning injury include hypoxic
encephalopathy and intracranial hemorrhage. The
usual locations of intracranial hemorrhage in lightning injury are the basal ganglia and brainstem.96-99
Cerebral infarction is a rare but possible complication.100-101 Delayed neurologic sequelae include
motor neuron disease and movement disorders,
although it is difficult to establish a clear association
with lightning strikes. Traumatic falls associated
with a lightning strike may result in spinal cord
injury and epidural and subdural hematomas. Additionally, lightning injury survivors may experience
persistent behavioral and neuropsychological effects
such as memory and attention deficits, posttraumatic stress disorder (PTSD), depression, and chronic
fatigue. In one case series involving patients with
lightning injuries seen in a neurology clinic, neuropsychological testing revealed mild impairments in
memory, attention, and visual reaction times in all
6 patients studied.102 Two of the patients were also
diagnosed with depression, and one showed convincing evidence of PTSD. This study was obviously
limited by its small size and selection bias, but it
does point out some interesting findings.
Once cardiopulmonary arrest, spinal cord injury,
intracranial injury, or other blunt injury have been
excluded, the management of lightning victims
should be supportive and symptomatic. Lightning
injury is distinct from high-voltage electrical injury,
and it should be treated as such to avoid iatrogenic
morbidity and mortality.87 Because lightning strike
patients rarely sustain burns or soft tissue injuries,
they generally do not require fluid resuscitation or
surgical decompression of their extremities.
Electrical Injuries In Children
Most electrical injuries in young children occur in
the home and are usually associated with electrical
cords (60-70% of cases) and wall outlets (10-15% of
cases).103 The most common injury seen in young
children is an oral arc burn, caused when the end
of a live extension cord is put in the mouth or when
the cord is bitten. These oral burns can be devastating and can result in injury to the commissure
of the lip, the tongue, or the floor of the mouth.
Electrical burns to the tongue and mouth can bleed
significantly and put these patients at risk for
aspiration. Swelling of the tongue and floor of the
mouth may be extensive and can lead to airway
obstruction. Hospital admission for airway observation or intervention and parenteral support is
often required in cases of severe electrical burns to
the orofacial region.104
Because of the risk to developing dentition and
the possibility of a poor cosmetic outcome, patients
with orofacial electrical injuries require surgical and
dental consultation for oral splinting (ie, at the lip
commissure), postburn debridement, and possible
reconstructive surgery.3,26 Severe bleeding from the
labial artery occurs in about 5% to 10% of patients
with oral burns when the eschar separates up to 2
weeks after the initial electrical injury.28,104 Educating parents on how to control bleeding from the
labial artery is crucial for outpatient management of
these injuries.
In general, children experience many of the
same injuries as adults following electrical trauma.
The anatomical and physiologic characteristics of
children, such as thinner skin, make them more
susceptible to severe injuries, especially in the extremities.50 Surgical consultation should be obtained
early with regard to the need for debridement and
fasciotomy.
Chen and Sareen103 attempted to determine
if cardiac monitoring is necessary in children by
performing a systematic review encompassing 7
retrospective studies, each involving a minimum of
35 patients. They concluded that otherwise healthy
children who are exposed to common household
electric current (low-voltage, no water contact)
and who are asymptomatic in the ED and have no
evidence of arrhythmia or cardiac arrest in the field
Figure 2. Feathering Burn
(Reprinted by permission from Elsevier. This figure was published in
Rosen’s Emergency Medicine Concepts and Clinical Practice, Price
TG and Cooper MA, Electrical and lightning injuries, 2267-2278,
Copyright © Elsevier 2006.)
October 2009 • EBMedicine.net
9
Emergency Medicine Practice © 2009
Clinical Pathway For Managing Electrical Injuries
Check ABC’s. Perform history
and physical exam.
Obtain ECG; consider telemetry, O2,
labs (including CK, UA), IV fluids.
Low-voltage injuries
ECG normal
AND no history of loss of
consciousness,
arrhythmia,
or other injury
requiring admission. (Class II)
ECG with
evidence of
ischemia OR
history of loss of
consciousness,
arrhythmia,
or other injury
requiring admission. (Class II)
Discharge home.
(Class II)
Admit. (Class II)
High-voltage injuries
Already at burn center?
Yes
NO
Involve appropriate consultants
(surgery, orthopedics), perform
serial neurovascular exams of
extremities, and
admit to hospital.
(Class II)
Transfer to
regional burn
center for admission. (Class II)
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and
effectiveness
Level of Evidence:
• One or more large prospective
studies are present (with rare
exceptions)
• High-quality meta-analyses
• Study results consistently positive and compelling
Class II
• Safe, acceptable
• Probably useful
Level of Evidence:
• Generally higher levels of
evidence
• Non-randomized or retrospective studies: historic, cohort, or
case control studies
• Less robust RCTs
• Results consistently positive
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments
Level of Evidence:
• Generally lower or intermediate
levels of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Indeterminate
• Continuing area of research
• No recommendations until
further research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American
Heart Association and represen-
tatives from the resuscitation
councils of ILCOR: How to Develop Evidence-Based Guidelines
for Emergency Cardiac Care:
Quality of Evidence and Classes
of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee
and Subcommittees, American
Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care.
JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2009 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC.
Emergency Medicine Practice © 2009
10
EBMedicine.net • October 2009
may be safely discharged without an initial ECG
or any inpatient cardiac monitoring. Although the
literature on high-voltage pediatric electrical injuries
is more limited, some authors recommend admitting
patients with these injuries for cardiac monitoring.28
age across the target’s body is approximately 1200
V (delivered in rapid pulses over 5 seconds), and
the average current is approximately 2.1 mA.109 The
electric shock delivered by the Taser® is neither pure
AC nor pure DC and is probably similar to rapid,
low-amplitude DC shocks.110
After reports of deaths in police custody following Taser® use, concern has been raised regarding its
safety.111 However, a recent small prospective study
by Ho et al109 found no evidence of Taser®-induced
cardiac arrhythmias, ECG changes, or electrolyte
abnormalities. Additionally, a prospective series involving 218 patients shot with the original Taser® in
the early 1980s described 3 deaths secondary to cardiac arrest; however, all 3 of these patients had high
levels of phencyclidine (PCP) in their blood, and
this was cited as the cause of death.112 The authors
concluded that the death rate in their series was no
higher than that reported for PCP toxicity alone.
Although data regarding the effects of the Taser®
are limited, it appears most healthy subjects may be
safely discharged from the ED after dart removal
and evaluation for any other injuries. Although
some authors recommend an ECG in patients who
have been shot with the Taser®, no current evidence
supports this practice.110
Electrical Injuries In Pregnant Women
The management of the pregnant woman after an
electrical injury should focus on protecting the wellbeing of both mother and fetus. The obstetrical team
should be consulted as soon as possible, and fetal
heart monitoring should be initiated for any patient
beyond 20 weeks’ gestation. Fetal monitoring and
tocodynamometry are indicated in electrical injuries
that involve any mechanical trauma because of the
potential for placental abruption.105 Ultrasonography to assess fetal viability may also be prudent,
especially if the patient experiences decreased fetal
movement, vaginal bleeding, fluid leakage, or abdominal pain. Close obstetrical follow-up is mandatory if the patient is discharged. Burns have adverse
effects on a pregnancy because they increase spontaneous uterine activity and affect circulation to the
uteroplacental unit secondary to volume shifts; thus,
aggressive care is needed in these cases.106
Scant literature is available on fetal outcome in
pregnant women who have been exposed to electrical injury. There are numerous case reports of fetal
demise following electrical trauma, with a cumulative fatality rate of around 73%.107 Complications
have included spontaneous abortion, intrauterine
growth retardation, oligohydramnios, and sudden
cessation of fetal movement. A recent prospective
cohort study compared 31 pregnant women exposed
to an electric shock (mostly low-voltage) between
4 and 36 weeks’ gestation with a matched control
group. Of the 31 exposed women, 28 gave birth to
healthy infants, 1 had a child with a ventricular
septal defect, and 2 had spontaneous abortions.
In the control group, 30 healthy babies were born,
and there was 1 spontaneous abortion. The authors
concluded that most cases of electrical injury do not
pose a major risk to the fetus, although it must be
noted that patients in their study had a much lower
rate of transuterine current than did patients in previous case studies.108
Controversies/Cutting Edge
Cardiac Monitoring After Electrical Injury
Electrical injuries can cause cardiac arrest, cardiac
arrhythmias, and even direct myocardial damage.
However, it is not always clear which patients need
to be admitted to the hospital for cardiac monitoring
and for what duration. Traditionally, patients with
low-voltage electrical exposure who have a normal ECG on presentation and no history of loss of
consciousness or arrhythmia have been discharged
home without cardiac monitoring.19 This practice
is supported in the guidelines recommended by
Arnoldo et al.8 (See Table 1, page 2.) Application
of the guidelines to the pediatric population is also
safe.24-26,103,113 In fact, Chen and Sareen concluded
that some low-risk children do not even require an
initial ECG.103
The literature on cardiac monitoring in highvoltage electrical injury is especially sparse. Bailey
et al21 recently published a multicenter prospective
study involving 134 patients who had at least one of
the following risk factors prompting the use of cardiac monitoring: transthoracic current, tetany, loss of
consciousness, or a high-voltage injury (> 1000 volts).
None of the patients in this study developed late
potentially lethal arrhythmias. Most of the patients
had transthoracic current and/or tetany as a risk factor, leading the authors to conclude that these patients
could be safely discharged from the ED if their initial
ECG results were normal. For the few patients with
Taser®
With increased use of conducted electrical weapons
(ie, Tasers®) by law enforcement agents and by civilians seeking personal protection, emergency clinicians can expect to see more patients in the ED with
Taser® injuries. Tasers® use compressed nitrogen to
fire 2 metallic darts up to 35 feet and transmit an
electrical impulse through up to 2 inches of clothing.
The Taser® causes involuntary contractions of the
regional skeletal muscles and makes it impossible
for the target to move voluntarily. The peak voltOctober 2009 • EBMedicine.net
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Emergency Medicine Practice © 2009
be referred to a burn center.77 No qualifiers are
included with this recommendation, so decisions
about which patients truly require transfer are left
to the emergency clinician’s discretion. Patients with
extensive electrical burns will likely require multiple
surgeries and extensive occupational and physical
rehabilitation and are best served at a burn center.
Patients who have abnormal neurologic findings
suggestive of spinal cord injury or CNS dysfunction
or who have extensive visceral or vascular injury
require admission to the intensive care unit or to an
area with a similar level of care for frequent monitoring and rapid intervention. Additionally, all patients
with a history of loss of consciousness, documented
arrhythmias either before or after arrival to the ED
(including cardiac arrest), ECG evidence of ischemia,
or who have a sustained a high-voltage electrical injury should be admitted for additional monitoring.8
high-voltage electrical injuries, the authors suggested
that cardiac monitoring be continued until adequate
evidence supports a recommendation. Most patients
with high-voltage electrical trauma have sufficient
injuries to require admission anyway.
No published studies have directly evaluated
the optimal duration of cardiac monitoring after
electrical injury. Currently, this decision is left to the
clinician. In several studies, the reported monitoring time was 24 hours after admission if the initial
ECG was normal or 24 hours after resolution of any
arrhythmias.25,28,114
Disposition
According to the American Burn Association’s burn
center referral criteria, patients with injuries due to
electrical burns, including lightning injury, should
Risk Management Pitfalls For Electrical Injuries (Continued on page 13)
1. “Results from the patient’s eye examination
were normal when he presented to the ED after
a lightning injury last month. I don’t know
why he’s back now weeks later complaining of
decreased vision.”
Cataracts is a common sequela of lightning
injury and can also be seen after electrical injury.
Cataracts may affect one or both eyes. They may
be present at the time of injury but often don’t
develop until weeks to months after the initial
insult. All patients presenting after electrical or
lightning injury should be warned of this possible complication, and ophthalmology followup should be arranged as needed.
4. “I saw this patient in the ED 3 months ago with
a minor electrical injury to her hand. I don’t
know why she’s back now complaining of diffuse pain, swelling, and coolness of her entire
forearm.”
Complex regional pain syndrome (CRPS),
formally called reflex sympathetic dystrophy, is
a recognized delayed complication of electrical
injuries. Patients with CRPS often present months
after their initial injury. CPRS is a clinical diagnosis, and symptoms include diffuse pain (often
involving a much larger area than the original
injury), swelling, decreased range of motion,
and temperature or skin color differences. This
chronic condition requires long-term care involving multiple specialists.
2. “I used the Parkland burn formula to estimate
the patient’s fluid resuscitation needs. I don’t
understand why he is still hypotensive and his
urine output is poor.”
Electrical injuries are different from purely
thermal burns. They are closer to crush injuries
because there may be extensive soft tissue and
muscular injury that is not obvious from the
surface. Because cutaneous burns from electrical injuries do not represent the full extent of
injury, formulas for fluid resuscitation based on
percentage of body surface area burned are not
applicable. Fluid resuscitation should maintain a
urine output of 1.0 to 1.5 cc/kg per hour.
5. “This patient who was struck by lightning
was slightly confused on arrival to the ED and
couldn’t remember what had happened to him.
I thought this was true of almost all people
struck by lightning and was nothing to be too
concerned about.”
3. “The patient’s shoulder appeared normal on
examination and an anteroposterior (AP) radiograph looked fine to me. I don’t know how I
missed a posterior dislocation.”
Emergency Medicine Practice © 2009
Shoulder dislocation can occur after electrical
injury secondary to tetanic muscle contractions
or from falls. Posterior dislocations are difficult
to diagnose because the external appearance of
the shoulder and an AP radiograph view may be
deceptively normal. Key signs to look for on examination are an arm fixed in internal rotation,
pain on abduction, and pain on external rotation. An axillary or transscapular view is often
needed to make the diagnosis radiographically.
12
EBMedicine.net • October 2009
Summary
Patients with low-voltage electrical injury who
are asymptomatic or have only mild cutaneous
burns, normal ECG results, and no history of loss of
consciousness may be safely discharged home. It is
important to give these patients clear instructions
for follow-up and information about which symptoms should lead them to seek medical treatment.
For example, patients with electrical injuries should
immediately return to the ED if they develop chest
pain, palpitations, lightheadedness, loss of consciousness, signs or symptoms of wound infection
(fever, worsening erythema, purulent discharge), or
cold, mottled, or painful extremities. They should
also be alert for the delayed development of cataracts, neurologic symptoms (weakness, paresthesia,
CRPS), and neuropsychological effects (memory and
attention problems, depression).
Although electrical injuries are uncommon, all
emergency physicians will face them at some
point. The management of electrical injuries is
challenging because patients present with a broad
spectrum of complaints and injuries. Patients with
electrical injuries can have complex multitrauma
and multiorgan issues, and early care is crucial
for a good outcome. Emergency clinicians should
remember these important points: (1) ECG for all
patients and cardiac monitoring when indicated,
(2) fluid resuscitation to prevent hypovolemia
and renal failure, and (3) frequent neurovascular
checks for signs of compartment syndrome in any
involved extremities.
Risk Management Pitfalls For Electrical Injuries (Continued from page 12)
Patients with lightning injuries often sustain loss
of consciousness, memory loss, or confusion associated with event. However, these patients are
also at high risk for traumatic brain injury secondary to falls or blunt trauma associated with
the lightning injury. Any patient whose mental
status does not rapidly improve or who has
external evidence of head injury should undergo
a head CT scan in the ED.
6. “I did a neurovascular exam on this patient’s
arm when he arrived in the ED 4 hours ago.
I don’t understand why he has compartment
pressures of 50 mm Hg now.”
Compartment syndrome may develop at any
time in patients with electrical injuries. It is
essential to continue frequent neurovascular
checks on these patients and to involve surgical
consultants early on.
9. “I have read a lot about electrical injuries, and
I know how important fluid resuscitation is. I
tried fluid resuscitation for my patient with a
lightning strike injury, and he ended up with
flash pulmonary edema.”
Lightning injuries are distinct from electrical
injuries and should be managed as such. Myoglobinuria is rare after lightning injury, and
patients with lightning injuries generally do not
require aggressive fluid resuscitation. Management of lightning injuries is largely supportive.
7. “The patient was awake and alert when he came
in, talking up a storm. The burns on his face
didn’t seem to bother him at all. I don’t understand how he ended up with a crash airway.”
Similar to patients with thermal burns, patients
with electrical injuries and burns involving the
face, mouth, or neck should be evaluated for a
difficult airway. These patients may have unseen
swelling or injury as a result of their exposure
and may rapidly lose their airway. Establishment of an early definitive airway is imperative
when this concern exists.
10. “I took care of this 3–year-old girl 2 weeks ago
when she presented with an oral arc burn. She
was healing well. I don’t understand why she
is back now with severe bleeding.”
Oral arc burns are very common in children who
bite into electric cords. In 5% to 10% of cases,
there may be severe bleeding from the labial
artery when the eschar separates, which can occur up to 2 weeks after the initial burn. Parents
should be preemptively instructed on how to
control such bleeding.
8. “When that lightning strike patient came in
October 2009 • EBMedicine.net
with pulseless, blue legs I thought he must
have thrown a clot. I thought I was doing the
right thing when I started him on a heparin
infusion. Now he has a head bleed and needs
neurosurgical intervention.”
Keraunoparalysis is pathognomonic for lightning
injury. It is a form of temporary paralysis where
the extremities are numb, blue, cold, and pulseless.
It usually resolves on its own within a few hours
and does not require any specific treatment.
13
Emergency Medicine Practice © 2009
Case Conclusion
CPR and held off on treating the other 2 patients until
this critical patient was stabilized. You were certain
these patients would survive even if they had to wait
longer to be evaluated. After several cycles of CPR and
epinephrine and atropine, the first patient regained normal sinus rhythm. You cheered silently and then moved
on to the secondary survey.
The electrician who came in after being found unconscious near a generator remained confused throughout
his ED stay. You made sure he had a C-collar in place and
ordered head and C-spine CT scans. You also obtained
an initial ECG and continued telemetry. After sending
off labs, including a CK and myoglobin level, you began
IV fluids for a goal urine output of 1.0 to 1.5 cc/kg per
hour. A surgical consultant evaluated the patient’s upper
extremities, and you conducted frequent neurovascular
checks. Once the patient was stabilized, you transferred
him to the regional burn center. When you followed up
on the patient’s course, you learned that he underwent
fasciotomy of his right upper extremity for compartment
syndrome that developed 12 hours after his initial injury.
The young lady shocked by her hair dryer remained
relatively asymptomatic, complaining only of mild pain
from the superficial burns on her right palm. The results
of her initial ECG were normal. You applied a clean, dry
dressing to her palm, gave her a tetanus vaccination, and
discharged her home with instructions to follow up with
her primary doctor in the next few days. You also instructed her to return to the ED if she develops chest pain,
palpitations, lightheadedness, or loss of consciousness.
The minute the 3 patients struck by lightning rolled
in, you ran to assist the patient in cardiac arrest. You
called for additional help and began CPR following
ACLS protocols. A definitive airway was placed, but the
patient remained pulseless and asystolic. You continued
Note
Full-color versions of the figures in this article
are available at no charge to subscribers at
www.ebmedicine.net/topics.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
random­ized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study,
such as the type of study and the number of patients
in the study, will be included in bold type following
the ref­erence, where available. In addition, the most
infor­mative references cited in this paper, as determined by the authors, will be noted by an asterisk (*)
next to the number of the reference.
Cost-Effective Strategies
1. Admit patients solely for cardiac monitoring
only if they have sustained a high-voltage injury or have a history of loss of consciousness,
cardiac arrhythmia either before or during
their presentation to the ED, or ECG evidence
of ischemia.
Risk Management Caveat: Be sure that all patients
sent home without cardiac monitoring follow up
with their primary doctors and that they have
received explicit instructions to seek medical attention if they develop any cardiac symptoms.
discharge from the wound, and treated with
antibiotics as needed.
3. According to the American Burn Association
recommendations, all patients with electrical injuries should be transferred to a burn
center.77 This recommendation does not differentiate between low-voltage and high-voltage
injuries or between severity of injuries. Obviously, there will be some electrical trauma
victims whose injuries are so minor that they
can be adequately treated at the local ED. It is
left to the discretion of the emergency clinician
to determine which electrical injury patients
truly require transfer.
Risk Management Caveat: Patients with highvoltage electrical injuries or evidence of severe
or extensive electrothermal burns and patients
requiring consultations with specialists should
be transferred to a regional burn center as soon
as possible.
2. Electrical burns, similar to thermal burns, may
be complicated by infection. While the tetanus
vaccine is often given to patients with electrical injuries, there is no evidence to support
the use of prophylactic antibiotics for systemic
effect.
Risk Management Caveat: Electrical burn patients should be monitored closely for signs and
symptoms of infection such as fever, worsening erythema around the burn site, or purulent
Emergency Medicine Practice © 2009
14
EBMedicine.net • October 2009
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CME Questions
97. Ozgun B, Castillo M. Basal ganglia hemorrhage related to
lightning strike. AJNR Am J Neuroradiol. 1995;16(6):1370-1371.
(Case report)
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98. Stanley LD, Suss RA. Intracerebral hematoma secondary
to lightning stroke: case report and review of the literature.
Neurosurgery. 1985;16(5):686-688. (Case report)
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99. Wakasugi C, Masui M. Secondary brain hemorrhages associated with lightning stroke: report of a case. Nihon Hoigaku
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(Case report)
101. Cherington M, Yarnell P, Lammereste D. Lightning
strikes: nature of neurological damage in patients evalu-
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17
Emergency Medicine Practice © 2009
1. Which tissue has the highest resistance?
a. Skin
b. Nerve
c. Bone
d. Muscle
8. Which statement regarding conducted electrical weapons (ie, Tasers®) is true?
a. They are known to cause cardiac arrhythmias.
b. They cause involuntary contractions of
regional skeletal muscles leading to immobilization of the victim.
c. They utilize only DC currents.
d. Patients with a Taser® injury should always
be admitted for cardiac telemetry.
2. Which statement regarding high-voltage injuries is NOT true?
a. High-voltage injuries involve more than
1000 volts.
b. High-voltage injuries rarely cause deep
burns.
c. High-voltage injuries require transfer to a
regional burn center.
d. High-voltage injuries require admission for
cardiac monitoring.
9. Which statement describes why AC is considered more dangerous than DC?
a. AC causes tetanic muscle contractions that
prolong contact with the electrical source.
b. AC has a higher voltage.
c. AC causes more traumatic injuries secondary to falls.
d. AC is more likely to result in associated
thermal burns.
3. Which is a rare consequence of electrical injury?
a. Acute myocardial infarction
b. Cardiac arrest
c. Compartment syndrome
d. Spinal cord injury
10. What is the top priority in providing prehospital care to patients with electrical injuries?
a. Initiating CPR as quickly as possible in patients with cardiac arrest.
b. Transporting patients as rapidly as possible
to a regional burn center.
c. Placing C-collars on patients to stabilize any
possible cervical spine injuries.
d. Ensuring that the electrical source has been
turned off and that it is safe for rescuers to
approach the victim.
4. What is the main treatment for myoglobinuria?
a. Sodium bicarbonate to alkalinize the urine
b. Furosemide to improve diuresis
c. Mannitol to increase urine output
d. IV fluid to maintain urine output of 1.0 to
1.5 cc/kg per hour
5. Which is more commonly associated with electrical injury than with lightning injury?
a. Cardiac arrest
b. Neurologic symptoms
c. Cataracts
d. Significant burns or soft tissue injury
11. Which diagnostic tool has NOT been shown
to be helpful in managing adult patients with
electrical injuries?
a. ECG
b. Basic laboratory tests including complete
blood cell count, electrolytes, serum urea
nitrogen/creatinine, and urinalysis.
c. Troponin
d. Creatine kinase
6. Which patient may be safely discharged home
from the ED?
a. A young man who sustained a high-voltage
injury and has deep burns to his upper extremities.
b. A middle-aged female presenting after a
low-voltage injury who is asymptomatic
and has a normal ECG.
c. A young woman presenting after a low-voltage injury who had a transient arrhythmia
on arrival to the ED.
d. A middle-aged man who sustained a lowvoltage injury and who is asymptomatic but
has new ST segment changes on ECG.
12. Which is NOT a standard treatment for cutaneous electrothermal injuries?
a. Clean dry dressings placed in the field
b. Prophylactic systemic antibiotics to protect
against clostridial myositis
c. Antibiotic dressings such as mafenide acetate or sulfadiazine silver
d. Tetanus vaccination
7. Which is NOT an indication for surgical decompression of an upper extremity electrical
injury?
a. Progressive neurologic dysfunction
b. Increased compartment pressure
c. Joint dislocation
d. Vascular compromise
Emergency Medicine Practice © 2009
18
EBMedicine.net • October 2009
Physician CME Information
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May 2009 Errata
In the May 2009 issue of Emergency Medicine Practice,
“Complications in Pregnancy Part II: Hypertensive Disorders of Pregnancy and Vaginal Bleeding,” there are two
errors.
1. On page 9 (right column, first paragraph), the sentence
incorrectly reads: “A contained acute hemorrhage
will appear hyperechoic…” The corrected sentence
reads: “A contained acute hemorrhage will appear
hypoechoic…”
2. In Table 9, the side effects for nitroprusside and nitroglycerine are reversed. The side effect of nitroprusside
is “cyanide production.” The side effects for nitroglycerine are “headache, tachycardia, methemoglobinemia,
increased intracranial pressure.”
We regret the errors and apologize for any confusion.
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October 2009 • EBMedicine.net
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Emergency Medicine Practice © 2009
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Emergency Medicine Practice © 2009
20
October 2009 • EBMedicine.net
EVIDENCE-BASED practice RECOMMENDATIONS
Electrical Injuries: A Review For The Emergency Clinician
Czuczman AD, Zane RD. October 2009; Volume 11, Number 10
This issue of Emergency Medicine Practice focuses on the challenges of evaluating and managing electrical injuries, using the best available evidence from the literature. For a more detailed discussion of this topic, including figures and tables, clinical pathways, and other
considerations not noted here, please see the complete issue at www.ebmedicine.net/topics.
Key Points
Comments
Survey the scene carefully and make sure the electrical source has
been shut off before approaching any victims of electrical injury.
Although no published reports describe this, the underlying theory
presumes that if the victim is still in contact with the electrical
source, he or she (or even the ground if it is wet) can become a conductor and electrocute the rescuer.
Always start with the ABCs, and follow basic Advanced Cardiac
Life Support and Advanced Trauma Life Support algorithms.
Take note of any electrothermal burns involving the face, mouth, or
neck, as they may make obtaining a secure airway more difficult.
Also look for tympanic membrane rupture during the otoscopic
examination, as this may be the only clue of lightning injury in a
patient brought from the field.55
Obtain an initial ECG for all adult patients.8
An ECG should be obtained for both low-voltage and high-voltage
injuries.
Use cardiac monitoring for patients with arrhythmia or evidence of
ischemia on electrocardiogram, loss of consciousness, and highvoltage (> 1000 volts) injuries.8,19,21,103
This recommendation is based on the practice guidelines developed
by Arnoldo et al and published in the Journal of Burn Care and
Research in 2006 using Class II and Class III evidence.8
Watch out for rhabdomyolysis in electrical injury patients, especially If heme pigment from rhabdomyolysis is present in the urine, urine
those with a high-voltage injury.
output must be constantly monitored.
Do not use any formula for IV fluid resuscitation that is based on
percentage of body surface area burned. These formulas are not
applicable in electrical injuries because there may be significant
underlying musculoskeletal injury.
Fluid resuscitation should maintain a urine output of 1.0 to 1.5 cc/kg
per hour.76
Involve consultants early on and consider transfer to a regional burn
center for any patients with significant electrothermal burns.77
Patients with extensive electrical burns will likely require multiple
surgeries and occupational and physical rehabilitation and are best
served at a burn center. Patients who have abnormal neurologic findings suggestive of spinal cord injury, CNS dysfunction, or extensive
visceral or vascular injury require admission to ICU or an area with
a similar level of care for frequent monitoring and rapid intervention. All patients with a history of loss of consciousness, documented arrhythmias (including cardiac arrest) before or after arrival to the
ED, ECG evidence of ischemia, or who have a sustained a high-voltage electrical injury should be admitted for additional monitoring.8
Immediately remove any constricting objects such as rings because
edema may develop quickly.
Vascular injuries can also lead to edema and/or compartment syndrome. Vascular injury following electrical trauma is usually most
severe in the small muscle branches where the blood flow is slower;
this can create tissue necrosis.37
See reverse side for reference citations.
5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 or 678-366-7933
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REFERENCES
These
references are
excerpted from
the original
manuscript.
For additional
references and
information on
this topic, see
the full text
article at
ebmedicine.net.
8. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res.
2006;27(4):439-447. (Guideline review via MEDLINE literature search)
19. Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department after electrical
injury with a management protocol. Postgrad Med J. 2002;78(919);283-285. (Prospective; 212 patients)
21. Bailey B, Gaudreault P, Thivierge RL. Cardiac monitoring of high-risk patients after an electrical injury: a prospective
multicentre study. Emerg Med J. 2007;24(5):348-352. (Prospective; 134 patients and 31 controls)
37. Hunt JL, McManus WF, Haney WP, Pruitt BA Jr. Vascular lesions in acute electrical injuries. J Trauma.
1974;14(6):461-473.
55. Cherington M, Kurtzman R, Krider EP, Yarnell PR. Mountain medical mystery: unwitnessed death of a healthy young
man, caused by lightning. Am J Forensic Med Pathol. 2001;22(3):296-298. (Case report)
76. Gupta KL, Kumar R, Sekhar MS, Sakhuja V, Chugh KS. Myoglobinuric acute renal failure following electrical injury.
Ren Fail. 1991;13(1):23-25. (Retrospective; 8 patients)
77. Gómez R, Cancio LC. Management of burn wounds in the emergency department. Emerg Med Clin North Am.
2007;25(1):135-146. (Review)
103. Chen EH, Sareen A. Do children require ECG evaluation and inpatient telemetry after household electrical exposures?
Ann Emerg Med. 2007;49(1):64-67. (Guideline review via MEDLINE literature search)
CLINICAL RECOMMENDATIONS
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Copyright © 2009 EB Practice, LLC. All rights reserved.
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